Central Journal of Family Medicine & Community Health

Cite this article: Kahana E, Lee JE, Kahana B, Langendoerfer KB, Marshall GL (2015) Patient Planning and Initiative Enhances Physician Recommendations for Cancer Screening and Prevention. J Family Med Community Health 2(8): 1066.

Abstract

Background: The growing population of older adults is at the highest risk for cancer, yet they are underserved in terms of cancer prevention and care. Discussions between patients and physicians that result in tailored recommendations are now called for by the U.S. Preventive Services Task Force.

Aims & Method: The current study explored the role of physician-patient relationships and of patient initiatives in health communication on primary care physicians’ recommendations of cancer prevention and screening. Our data was collected from baseline questionnaires from elderly patients 60 years of age or older (N=360) who attended an adult community center where an educational intervention was administered.

Results: Our findings demonstrate the importance of elderly patients’ advocacy, shown through planning and initiative in communication for eliciting doctor’s cancer screening and cancer prevention recommendations in primary care settings.

*Corresponding authorEva Kahana, Department of Sociology, Case Western Reserve University, 10900 Euclid Avenue, MTHM 226, Cleveland OH 44106-7124, USA, Tel: 216-368-2704; Fax: 216-368-2676; Email:

Submitted: 30 November 2015

Accepted: 17 November 2015

Published: 19 December 2015

ISSN: 2379-0547

Copyright© 2015 Kahana et al.

OPEN ACCESS

Keywords•Doctor patient relationship•Cancer screenings•Elderly patients’ advocacy

Short Communication

Patient Planning and Initiative Enhances Physician Recommendations for Cancer Screening and PreventionEva Kahana1*, Jeong Eun Lee2, Boaz Kahana3, Kaitlyn Barnes Langendoerfer1 and Gillian L. Marshall4

1Department of Sociology, Case Western Reserve University, USA2Department of Human Development and Family Studies, Kent State University, USA3Department of Psychology, Cleveland State University, USA4School of Social Work, University of Washington, USA

ABBREVIATIONSHCP: Health Care Partnership; FOBT: Fecal Occult Blood Test;

PSA: Prostate-Specific Antigen

INTRODUCTIONThe standard of care in U.S. communities includes the

administration of cancer screening tests recommended by the American Cancer Society [1-3]. In practice, cancer screening tests and cancer prevention recommendations in primary care for older adults are often based on expert or physician opinions without much attention to patients’ wishes [4]. We used our previously developed Health Care Partnership Model (HCP) as the conceptual background for exploring our research question [5].

This model proposes that the more active and involved older patients are in their health communications with physicians, the better their health care will be [5]. We also recognize that patients’ demographic characteristics (e.g., age, gender, education) influence the number of physicians’ cancer screening and cancer

prevention recommendations. Specifically, we expect that patient initiative and assertiveness in communication with physicians will enhance cancer prevention and screening recommendations [6,7]. The model also proposes that relational aspects of medical care (e.g., continuity of care, patient’s confidence in doctors) will affect the physician’s recommendation for cancer screening and cancer prevention [5].

STUDY OBJECTIVESBased on prior studies, we developed four study aims. First,

we wanted to examine whether there is any association between physician recommendations of cancer prevention and screening to community dwelling elderly patients. Second, we sought to examine how patients’ socio-demographic characteristics are associated with physicians’ cancer screening and prevention recommendations. Third, we considered the influence of aspects of the doctor patient relationship (continuity, confidence and patient satisfaction with doctor’s care) on physicians’ cancer prevention and screening recommendations. Finally, we examined the role of patient pro-activity on physicians’ cancer prevention and cancer screening recommendations.

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METHODS

Procedures and Sampling

Our data was collected from baseline questionnaires administered to community dwelling adults prior to an educational intervention. To be eligible for the study, patients had to be 60 years of age or older, attending AAA community centers in three different locales (Cleveland, OH; Newburgh, NY, and Miami, FL). Questionnaires were administered to program participants in small group settings at senior centers).The current study includes responses of 360 older adults residing in community.

Participants

Our study sample closely resembles that of national samples of older adults residing in community settings. Demographic characteristics of the sample included the following: 75% of participants (N=265) were women, age ranged from 60 to 98 and the average age was 77.3 (SD=7.79), over half of the sample was White (61%; N=214); others were African American (30%; N=79) or other ethnic minority groups (9%; N=16).The majority of participants (88%) reported having more than 12 years of education and participants reported generally good health status (range =1-5; M=3.84, SD=.68).

Measures

Cancer Screening Recommendation: The gender proper cancer screening tests recommended by primary care physicians were summed. Screening tests included: FOBT (Fecal occult blood test), Mammogram (women), PSA (Prostate-Specific Antigen-men), and Colonoscopy. Patients’ responses (1=Yes, 0=No) were summed to create an index of the cancer screening recommendations.

Cancer Prevention Recommendation: Physician’s prevention recommendations were based on the question “Did your doctor recommend the following?” Response items included: eating a healthy diet, increasing activity/exercise, using more sun protection, and stop smoking. Each response was binary (0=No, 1=Yes) and were summed to create a cancer prevention recommendation count, so that higher scores reflect higher cancer prevention recommendation.

Doctor-Patient Relationship: This was assessed by the length of time they had been a patient of their primary care doctor (continuity of care), the degree to which they had confidence in their doctor and the satisfaction they had in the quality of their doctor’s care (doctor’s care).

Patient Advocacy in Communication: Patients’ advocacy was based on a) asking the doctor questions, b) making suggestions for health care, c) speaking confidently with doctors, and d) taking an active role in health care. A mean score was created based on these four items, so that higher scores reflect higher patient advocacy.

Patient demographic and Health Characteristics: Patients were asked questions about their demographic characteristics and to rate their health on a five point Likert scale (1=very poor to 4=excellent).

Analyses

Descriptive information about patients, range of the scores for each measure and the correlation of key variables are presented in Table 1. To test our three study questions (question 2-4), we ran two hierarchical linear regression models. First, we included socio-demographic information of participants (i.e., age, gender, education and self-rated health). In the second step, we included the patient-doctor relationship variables (i.e., year of relationship, confidence in doctors, and doctor’s care). In the final step, we include a patient advocacy in communication as a predictor. In estimating two models, we included the number of cancer screening and cancer prevention recommendation as dependent variables. These results are presented in Table 2.

RESULTS

Cancer screening recommendation and cancer prevention recommendation

Our descriptive data indicate that the concordance between physicians’ prevention and cancer screening recommendations was low. That is, not all primary care physicians recommended both cancer prevention and screening for each patient. Older patients reported a mean number of cancer preventions recommendations of 1.82 (SD=.95) out of the 4 recommendations considered. In terms of cancer screening numbers, we obtained a mean of 1.77 (SD=1.19) for three gender proper screening tests suggested by physicians.

Patient Characteristics and Cancer Screening and Prevention Recommendation

In terms of patient demographics, we found that female patients received more cancer screening recommendation (β=-.388, p<.05). In addition, patients who rated themselves less healthy were more likely to receive more cancer screening recommendations (β=-.264, p<.05). In contrast, none of the patient demographic characteristics was associated with cancer prevention recommendation.

Doctor-Patient Relationship and Physician’s Cancer Screening and Prevention

Advice: There were no significant associations found between continuity of care, confidence in the physician or satisfaction with doctor’s care and cancer screening or prevention recommendations.

Patient Advocacy and Physicians’ Cancer Screening and Prevention Advice: Consistent with our hypothesis, participants’ advocacy predicted doctors’ prevention suggestions (β=.243, p<.05) and cancer screening test recommendations (β=.134, p<.05). That is, when patients showed higher initiatives in their communication with doctors, primary care physicians were more likely to recommend both cancer screening and cancer prevention to patients.

DISCUSSION AND CONCLUSIONOverall, our findings highlight the important role of

elderly patients’ advocacy, demonstrated in initiative and assertiveness in communication for eliciting cancer screening

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Table 1: Correlation Matrix of Key Variables (N=360).

1 2 3 4 5 6 7 8 9

1. Age --

2. Gender -.022

3. Education -.113* .037

4. Race -.278** .113* -.099

5. Health .051 .084 .203 -.185**

6. Years in Relationship .067 -.009 .010 -.155** .048

7. Confidence in Doctors -.038 -.006 .064 -.110 .082 .211**

8. Doctor’s Care .055 .070 -.090 -.012 .106 .145** .406**

9. Patient Advocacy .169** -.114* .055 -.080 -.150** .107 .113* .139** --

Mean (%) 77.3 75 2.79 61 3.84 9.29 3.44 3.33 1.75

Range 60-98 1-5 1-5 0-40 0-4 1-4. 0-4

Note: * p<.05; ** p<.01

Table 2: Predicting doctor’s recommendation for cancer screening and cancer prevention.

Cancer Screening Cancer Prevention

Predictor β β

Step 1

Age -.014 -.021

Gender -.388* .099

Race -.119 .043

Education -.008 .103

Health -.264* -.091

Step 2

Years of Relationship -.0058 .011

Confidence in Doctors .111 .089

Doctor’s Care .152 .117

Step 3

Patient Advocacy .243*** .134*

Note: *p<.05; **p<.01; *** p<.001

and cancer prevention recommendations from primary care physicians. Patient’s age and education were not associated with cancer screening recommendation or cancer prevention recommendations. However, gender and self-rated health were associated with cancer screening recommendation, indicating gender disparity issues and lack of attention on relatively healthy older adults.

Our finding that the correlation between cancer screening recommendation and cancer prevention counts are low reflect that physicians who would recommend screening may not go one step further in recommending other preventive tips for older patients in the primary setting or vice versa. Thus, it is noteworthy that patient advocacy influences both types of recommendations. This may reflect doctors’ willingness to offer patient responsive care whenever patients speak up and take an active role in their health care.

Surprisingly, key elements of the doctor-patient relationship, such as continuity of care, confidence in doctor or positive

evaluations of the doctor’s care were not associated with doctors’ prevention or screening recommendations. These findings call attention to the growing importance of patient initiatives and behaviors in influencing cancer prevention and screening. This finding is consistent with recognition that older patients’ values and preferences should play an important role in primary care.

Results of our study call attention to the value of enhancing communication skills and consumer advocacy among older adults [8,9]. Training may be particularly beneficial to older adults with limited education and low health literacy [6]. If primary care physicians do not discuss and recommend cancer prevention and cancer screening spontaneously as we found above, patients’ role in initiating and advocating for care in the primary care settings may be crucial in obtaining adequate health care. Furthermore interventions for targeting communication competence among older adults may contribute to better cancer prevention practices. Physician responsiveness to patient initiatives in communication may contribute to positive health outcomes of older patients [10,11]. Understandings gained from this research can elucidate

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new demands on primary care in an increasingly complex health care environment [12].

ACKNOWLEDGEMENTSFunded by The National Cancer Institute. Grant Number:

5RO1CA098966.

REFERENCES1. Kahana E, Cheruvu V, Kahana B, Kelley-Moore J, Sterns S, Brown J, et

al. Patient Advocacy and Cancer Screening in Late Life. Open Longev Sci Special Issue Enhancing Disability-Free Life Expectancy Through Proactive Lifestyles. 2010; 4: 20-29.

2. Smith RA, Manassaram-Baptiste D, Brooks D, Doroshenk M, Fedewa S, Saslow D, et al. Cancer screening in the United States, 2015: a review of current American cancer society guidelines and current issues in cancer screening. CA Cancer J Clin. 2015; 65: 30-54.

3. Sheridan SL, Harris RP, Woolf SH; Shared Decision-Making Workgroup of the US. Preventive Services Task Force. Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med. 2004; 26: 56-66.

4. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001; 285: 2750-2756.

5. Kahana E, Kahana B. Health Care Partnership Model of doctor-patient

communication in cancer prevention and care among the aged. Handbook of Communication and Cancer Care. 2007; 37-54.

6. Kreps GJ. The impact of communication on cancer risk, incidence, morbidity, mortality, and quality of life. Health Commun. 2003; 15: 161-169.

7. Rivera-Colón V, Ramos R, Davis JL, Escobar M, Inda NR, Paige L, et al. Empowering underserved populations through cancer prevention and early detection. J Community Health. 2013; 38: 1067-1073.

8. Cegala DJ, McClure L, Marinelli TM, Post DM. The effects of communication skills training on patients’ participation during medical interviews. Patient Educ Couns. 2000; 41: 209-222.

9. Hagan TL, Donovan HS. Self-advocacy and cancer: a concept analysis. J Adv Nurs. 2013; 69: 2348-2359.

10. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009; 74: 295-301.

11. Mittler JN, Martsolf GR, Telenko SJ, Scanlon DP. Making sense of “consumer engagement” initiatives to improve health and health care: a conceptual framework to guide policy and practice. Milbank Q. 2013; 91: 37-77.

12. Miller WL, Crabtree BF, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract. 1998; 46: 369-376.

Kahana E, Lee JE, Kahana B, Langendoerfer KB, Marshall GL (2015) Patient Planning and Initiative Enhances Physician Recommendations for Cancer Screening and Prevention. J Family Med Community Health 2(8): 1066.

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